Resuscitation 87 (2015) e5–e6
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Extracorporeal life support treatment bundle for refractory cardiac arrest Sir, We read with great interest the paper by Johnson et al.1 describing their 7-year institution’s experience with Extracorporeal Life Support (ECLS) for out-of-hospital (OHCA) and emergency department refractory cardiac arrest. In their series of 26 patients, four patients survived to discharge (15%) among whom three patients were neurologically intact at 6 months (11.5%, 3/26). Those promising, these results differ from the more encouraging ones reported in similar papers by Wang et al.2 and Fagnoul et al.3 in whom the Authors reported the experience of their own centers for patients who received ECLS for OHCA or in-hospital cardiac arrest (IHCA), respectively. In their series of 230 patients, Wang et al.2 reported survival to discharge of about 33% and a favorable outcome of about 25%. Similarly, Fagnoul et al.3 in a study population of 24 patients, reported a survival rate with good neurolocal outcome at day 28 in the 25% (6/24). The following factors may account for the discrepancies in outcome between the investigation by Johnson et al.1 and those by Wang et al.2 and Fagnoul et al.3 (Table 1): (a) stricter selection criteria adopted by Wang et al.2 and Fagnoul et al.,3 especially in respect to age, initial rhythm and no-flow/low flow times; (b) ECLS team expertise which can be inferred by shorter times from cardiac arrest
and ECLS initiation; (c) ECLS treatment bundle including the treatment of reversible cause (most frequently by cardiac reperfusion) and neurological protection by means of therapeutic hypothermia. While Johnson et al.1 did not mention the treatments/therapeutic approaches implemented in their patients during ECLS support, all patients enrolled by Fagnoul et al.3 underwent hypothermia during ECLS support (intra-arrest cooling was performed in 17 patients) and normoxemia (PaO2 was maintained between 60 and 150 mmHg) in order to avoid an increased production of reactive oxygen species. In the series by Wang et al.,3 cardiac reperfusion was performed in almost half of the population. The clinical relevance of the ECLS treatment bundle seems to be confirmed also by the results of the Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial) trial4 in whom survival to hospital discharge with full neurological recovery occurred in 14/26 (54%) patients and in particular, in the 60% of IHCA patients and in the 45% of OHCA patients. The available evidence coming from the recent investigations strongly suggests that ECLS support, especially when included in a well defined treatment bundle, is associated with favorable outcome in selected patients with refractory cardiac arrest. Therefore there is the clinical need for shared protocols in order to reduce differences related to the center experience and mostly to increase availability of ECLS as part of a multi-faceted approach for these patients.
Table 1 Selection criteria, times and ECLS treatment bundle. Selection criteria Age
Initial rhythm
Times
Witnessed cardiac arrest
1
Johnson et al.
18–70 years
Collapse to EMS arrive < 15 min
Witnessed cardiac arrest
Wang et al.2 Fagnoul et al.3
16–80 years
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Extracorporeal life support treatment bundle for refractory cardiac arrest Sir, We read with great interest the paper by Johnson et al.1 describing their 7-year institution’s experience with Extracorporeal Life Support (ECLS) for out-of-hospital (OHCA) and emergency department refractory cardiac arrest. In their series of 26 patients, four patients survived to discharge (15%) among whom three patients were neurologically intact at 6 months (11.5%, 3/26). Those promising, these results differ from the more encouraging ones reported in similar papers by Wang et al.2 and Fagnoul et al.3 in whom the Authors reported the experience of their own centers for patients who received ECLS for OHCA or in-hospital cardiac arrest (IHCA), respectively. In their series of 230 patients, Wang et al.2 reported survival to discharge of about 33% and a favorable outcome of about 25%. Similarly, Fagnoul et al.3 in a study population of 24 patients, reported a survival rate with good neurolocal outcome at day 28 in the 25% (6/24). The following factors may account for the discrepancies in outcome between the investigation by Johnson et al.1 and those by Wang et al.2 and Fagnoul et al.3 (Table 1): (a) stricter selection criteria adopted by Wang et al.2 and Fagnoul et al.,3 especially in respect to age, initial rhythm and no-flow/low flow times; (b) ECLS team expertise which can be inferred by shorter times from cardiac arrest
and ECLS initiation; (c) ECLS treatment bundle including the treatment of reversible cause (most frequently by cardiac reperfusion) and neurological protection by means of therapeutic hypothermia. While Johnson et al.1 did not mention the treatments/therapeutic approaches implemented in their patients during ECLS support, all patients enrolled by Fagnoul et al.3 underwent hypothermia during ECLS support (intra-arrest cooling was performed in 17 patients) and normoxemia (PaO2 was maintained between 60 and 150 mmHg) in order to avoid an increased production of reactive oxygen species. In the series by Wang et al.,3 cardiac reperfusion was performed in almost half of the population. The clinical relevance of the ECLS treatment bundle seems to be confirmed also by the results of the Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial) trial4 in whom survival to hospital discharge with full neurological recovery occurred in 14/26 (54%) patients and in particular, in the 60% of IHCA patients and in the 45% of OHCA patients. The available evidence coming from the recent investigations strongly suggests that ECLS support, especially when included in a well defined treatment bundle, is associated with favorable outcome in selected patients with refractory cardiac arrest. Therefore there is the clinical need for shared protocols in order to reduce differences related to the center experience and mostly to increase availability of ECLS as part of a multi-faceted approach for these patients.
Table 1 Selection criteria, times and ECLS treatment bundle. Selection criteria Age
Initial rhythm
Times
Witnessed cardiac arrest
1
Johnson et al.
18–70 years
Collapse to EMS arrive < 15 min
Witnessed cardiac arrest
Wang et al.2 Fagnoul et al.3
16–80 years
